QUESTION: I have recently been made aware that there is a code for maintenance care: S8990. Is this a real code? I cannot find it in CPT. And may I use it for Medicare?
You are indeed correct that S8990 is indeed a code for maintenance for physical therapy or manipulation. It is a Health Care Common Procedure Coding System (HCPCS) code and not part of the CPT coding set. HCPCS is a collection of codes that represent procedures, supplies, products and services which may be provided to Medicare beneficiaries and individuals enrolled in private health insurance programs.
Maintenance Care: What Medicare and Insurance Carriers Say It Is
S8990 is defined as physical or manipulative therapy performed for maintenance, rather than restoration. As such, it can be used to identify a service as maintenance. S8990 can be used for chiropractic adjustments once the patient has reached maximum therapeutic benefit and has transitioned to preventive/wellness care or performance-enhancing care.
Here is a typical definition of maintenance care by insurance carriers: "Preventive or maintenance chiropractic manipulation has been defined as elective health care that is used to prevent disease, promote health and enhance the quality of life. This care may be provided after maximum therapeutic improvement, without a trial of withdrawal of treatment, to prevent symptomatic deterioration or it may be initiated with patients without symptoms in order to promote health and to prevent future problems. Preventive services may include patient education, home exercises, and ergonomic postural modification."
Medicare (CMS) defines maintenance care as follows: "Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy."
Simplifying and amalgamating the definitions, clearly maintenance is treatment that is not "corrective" or results in a defined or clear functional level of restoration. In other words, it is what you think it is.
Restrictions on Use / Reimbursement
Even though Medicare does allow coding with some of the codes in the HCPCS set, this code cannot be used for a chiropractor to identify maintenance care for a Medicare beneficiary. Medicare requires that maintenance care be coded with the appropriate chiropractic manipulative therapy (CMT) code, 98940-98942, and be appended with modifier GA.
The modifier GA indicates that the patient has signed an Advanced Beneficiary Notice (ABN), form CMS-R-131. (As discussed in my previous article, the Medicare ABN has been updated; the new form is required as of June 21, 2017, with a new expiration date of March 2020. The new form [in English and Spanish] may be downloaded at https://www.cms.gov/medicare/medicare-general-information/bni/abn.html.) The patient signing the form understands that care is maintenance and will be their personal responsibility in terms of payment.
Conversely, since maintenance is not a typical covered service, it too would not be used for visits where care is maintenance and the patient would simply pay out of pocket. However, S8990 could be used on a patient receipt of a superbill. I suggest that for diagnosis, do not use subluxation or similar diagnosis so as to not infer any correction, but instead use the diagnosis code Z41.8, which is defined as an "other encounter for procedure purpose other than remedying health state."
Unless the patient's health care plan covers maintenance or supportive care, it is the responsibility of the patient, not the health care plan, to make payment.
Exceptions to the General Rule
Currently, only a few health care plans and/or employer groups provide coverage for maintenance or supportive care. As always, verify the coverage. A carrier may allow some supportive or maintenance care; if so, the correct code to use is indeed S8990. In addition, there can be a health savings (HSA)-type plan that may have an allowance whereby the code may be used.
Ultimately, be aware that plans you are registered with as a provider may require the patient to sign a waiver form prior to treatment (similar to Medicare) that states they understand care is maintenance, so you are protected if later, the patient attempts to bill and when denied as a non-covered service, wants to be refunded.
Editor's Note: Feel free to submit billing questions to Mr. Collins at sam@hjrossnetwork.com. Your question may be the subject of a future column.
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